Registered Nurse (RN) – Care Transition Coordinator

About the Opportunity

DaMar Staffing is seeking an experienced Registered Nurse (RN) for an LTSS Transition RN Coordinator opportunity supporting individuals transitioning from hospitals and other inpatient settings back into the community.

This is a highly collaborative, field-based nursing role focused on helping members and their families navigate safe, informed, and successful transitions of care. The RN Coordinator works alongside service coordinators, healthcare providers, inpatient teams, and other clinical partners to identify barriers, coordinate post-discharge needs, and help reduce avoidable hospital readmissions.

The ideal candidate is an experienced RN who is comfortable working independently, building relationships across healthcare settings, and traveling throughout an assigned Indiana territory.

What You'll Do

• Conduct in-person outreach to members, healthcare providers, hospitals, skilled nursing facilities, nursing facilities, and other stakeholders involved in transitions of care.
  
• Support person-centered care planning and help members and caregivers understand and actively participate in post-discharge care.
  
• Advocate for members throughout the care continuum and assist with identifying and resolving barriers to care.
  
• Collaborate with service coordinators, physicians, case managers, hospitalists, medical directors, Utilization Management, and interdisciplinary healthcare teams.
  
• Conduct structured clinical assessments to identify post-discharge needs, including:
  • Medication needs and reconciliation
    
  • Specialist and primary care follow-up
    
  • Home health services
    
  • Durable medical equipment
    
  • Caregiver support
    
  • Social and community-based needs
    
• Facilitate safe and timely discharge planning and appropriate follow-up care.
  
• Review medical and payer information in collaboration with Utilization Management to identify potential barriers to discharge.
  
• Monitor changes or risks related to members' LTSS, physical health, or behavioral health needs.
  
• Educate members and families regarding the plan of care, discharge instructions, follow-up requirements, and available resources.
  
• Document and track transition-of-care interventions according to established program procedures.
  
• Maintain compliance with applicable CMS, Indiana, and NCQA Transitions of Care requirements.
  
• Identify opportunities to improve workflows, partnerships, and the overall quality of member care.
  
• Report critical incidents to appropriate internal and external agencies when required.
  
• Participate in grievances, appeals, fair hearings, and state audits as needed.
  
• May serve as a mentor, subject matter expert, or preceptor for new team members and participate in process-improvement initiatives.
  

Required Qualifications

• Active Registered Nurse (RN) license in the State of Indiana in good standing.
  
• Minimum of 2 years of nursing experience in one or more of the following:
  • Transitional nursing
    
  • Emergency room nursing
    
  • Discharge planning
    
  • Home health
    
• Ability to work independently while collaborating effectively with multidisciplinary healthcare teams.
  
• Strong communication, relationship-building, and customer-service skills.
  
• Reliable transportation.
  

Preferred Qualifications

• Experience with inpatient care management or utilization management.
  
• Knowledge of Medicaid programs.
  
• Familiarity with NCQA regulatory requirements related to transitions of care.
  
• Experience coordinating care for individuals with complex medical, behavioral health, or long-term services and supports needs.
  
• Strong clinical judgment and independent problem-solving skills.
  
• Ability to evaluate opportunities for cost-effective care while maintaining high-quality patient outcomes.
  

Travel Requirements

This is a field-based position requiring approximately 80% travel to hospitals and healthcare facilities within an assigned Indiana region. Candidates must have reliable transportation and be available to travel primarily Monday through Friday between 8:00 AM and 5:00 PM.

Who Will Thrive in This Role?

This opportunity may be a strong fit if you are an RN who enjoys working beyond the traditional bedside environment and wants to make an impact during one of the most critical points in a patient's healthcare journey.

We're looking for someone who can combine clinical expertise, care coordination, advocacy, and relationship-building to help members successfully transition from inpatient care back into their homes and communities.

Apply Today

If you are an Indiana-licensed RN with experience in transitions of care, discharge planning, emergency nursing, or home health—and you're comfortable working in a highly mobile, field-based position—we encourage you to apply.